Reperfusion Therapies in STEMI

Primary Percutaneous Coronary Intervention (PCI) for STEMI

• Indication: STEMI patients with persistent ST-segment elevation
• Steps: Initial assessment, medical stabilization, catheterization, revascularization
• Complications: Bleeding, arrhythmias, stent thrombosis
• AHA/ESC guidelines: Early diagnosis, risk stratification, timely revascularization

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AHA STEMI Guidelines- PCI

Indications for Primary PCI

Indication	COR	LOE
Ischemic symptoms <12 h	I	A
Ischemic symptoms <12 h and contraindications to fibrinolytic therapy irrespective of time delay from FMC	I	B
Cardiogenic shock or acute severe HF irrespective of time delay from MI onset	I	B
Evidence of ongoing ischemia 12 to 24 h after symptom onset	IIa	B
PCI of a noninfarct artery at the time of primary PCI in patients without hemodynamic compromise	III	Harm B

2013 ACCF/AHA guideline. Circulation. 2013 Jan 29;127(4):e362-425.

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AHA STEMI Guidelines- Fibrinolytics

Indications for Fibrinolytic Therapy

Indication	COR	LOE
Ischemic symptoms <12 h	I	A
Evidence of ongoing ischemia 12 to 24 h after symptom onset, and a large area of myocardium at risk or hemodynamic instability	IIa	C
ST depression except if true posterior (inferobasal) MI suspected or when associated with ST-elevation in lead aVR	III	Harm B

2013 ACCF/AHA guideline. Circulation. 2013 Jan 29;127(4):e362-425.

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Alteplase for STEMI

• Mechanism:
  • Converts plasminogen to plasmin to degrade thrombus
• Dose
  • weight-based bolus dose of 15 mg/kg (maximum 100 mg) followed by a 0.75 mg/kg (maximum 50 mg) infusion over 30 minutes (up to a maximum of 100 mg).
• Pharmacokinetics:
  • Has a short half-life of about 5 minutes and is rapidly cleared from the circulation.
• Adverse Effects:
  • Bleeding, fever, allergic reactions, hypotension
• Clinical Pearls & Practical Considerations:
  • Check for contraindications
  • Patients should receive anticoagulant therapy following alteplase administration

Tenecteplase for STEMI

• Mechanism:
  • Converts plasminogen to plasmin to degrade thrombus
• Dose
  • <60 kg: 30 mg
  • 60-69 kg: 35 mg
  • 70-79 kg: 40 mg
  • 80-89 kg: 45 mg
  • 90 kg or more: 50 mg
• Pharmacokinetics:
  • Half-life: 20-24 minutes
  • Rapid absorption with peak plasma levels in 5-10 minutes
  • Cleared by liver and reticuloendothelial system
• Adverse Effects:
  • Bleeding: intracranial, GI, retroperitoneal, or from puncture sites
  • Allergic reactions: angioedema, anaphylaxis, urticaria
  • Hypotension, arrhythmias, reperfusion injury
• Clinical Pearls & Practical Considerations:
  • Compared to alteplase, tenecteplase has a longer half-life and is given as a single bolus
  • Check for contraindications
  • Patients should receive anticoagulant therapy following tenecteplase administration

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AHA STEMI Guidelines- P2Y12 Inhibitors

Antiplatelet Therapy to Support Reperfusion With Fibrinolytic Therapy

Drug	Recommendation	LOE	COE
Aspirin	•162- to 325-mg loading dose •81- to 325-mg daily maintenance dose (indefinite)	I	A
Aspirin	•81 mg daily is the preferred maintenance dose	IIa	IIB
Clopidogrel	•Age ≤75 y: 300-mg loading dose	I	A
Clopidogrel	•Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleeding	I	A (14 Day) C (up to a yr)
Clopidogrel	•Age >75 y: no loading dose, give 75 mg	I	A
Clopidogrel	•Followed by 75 mg daily for at least 14 d and up to 1 y in absence of bleeding	I	A (14 Day) C (up to a yr)

2013 ACCF/AHA guideline. Circulation. 2013 Jan 29;127(4):e362-425.

Antiplatelet Therapy to Support PCI After Fibrinolytic Therapy

Drug	Recommendation	LOE	COE
Clopidogrel
	•Loading dose (for patients who received a loading dose of clopidogrel with fibrinolytic therapy): Continue 75 mg daily without an additional loading dose	I	C
	•Loading dose (for patients who have not received a loading dose of clopidogrel): •If PCI is performed ≤24 h after fibrinolytic therapy: 300 mg before/at time of PCI	I	C
	•Loading dose (for patients who have not received a loading dose of clopidogrel): •If PCI is performed >24 h after fibrinolytic therapy: 600 mg before/at time of PCI	I	C
	DES or BMS placed: Continue therapy for at least 1 y with: ● Clopidogrel: 75 mg daily	I	C
Prasugrel
	● If PCI is performed >24 h after treatment with a fibrin-specific agent or >48 h after a non–fibrin-specific agent: prasugrel 60 mg at the time of PCI	IIa B	IIa B
	•Contraindicated (patients with STEMI and prior stroke or TIA)	III (harm)	B
	DES or BMS placed: Continue therapy for at least 1 y with: ● Prasugrel: 10 mg daily IIa B	IIa	B

2013 ACCF/AHA guideline. Circulation. 2013 Jan 29;127(4):e362-425.

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AHA STEMI Guidelines- Anticoagulants

Anticoagulant Therapy to Support Reperfusion With Fibrinolytic Therapy

Drug	Recommendation	LOE	COE
UFH	•Weight-based IV bolus and infusion adjusted to obtain aPTT of 1.5 to 2.0 times control for 48 h or until revascularization. •IV bolus of 60 U/kg (maximum 4000 U) followed by an infusion of 12 U/kg/h (maximum 1000 U) initially, adjusted to maintain aPTT at 1.5 to 2.0 times control (approximately 50 to 70 s) for 48 h or until revascularization.	I	C
Enoxaparin	•If age <75 y: 30-mg IV bolus, followed in 15 min by 1 mg/kg subcutaneously every 12 h (maximum 100 mg for the first 2 doses) •If age ≥75 y: no bolus, 0.75 mg/kg subcutaneously every 12 h (maximum 75 mg for the first 2 doses) •Regardless of age, if CrCl <30 mL/min: 1 mg/kg subcutaneously every 24 h •Duration: For the index hospitalization, up to 8 d or until revascularization	I	A
Fondaparinux	•Initial dose 2.5 mg IV, then 2.5 mg subcutaneously daily starting the following day, for the index hospitalization up to 8 d or until revascularization •Contraindicated if CrCl <30 mL/min	I	B

2013 ACCF/AHA guideline. Circulation. 2013 Jan 29;127(4):e362-425.

Anticoagulant Therapy to Support PCI After Fibrinolytic Therapy

Drug	Recommendation	LOE	COE
UFH	•With GP IIb/IIIa receptor antagonist planned: 50- to 70-U/kg IV bolus to achieve therapeutic ACT of 200 to 250 s. •GP IIb/IIIa receptor antagonist planned: 70- to 100-U/kg bolus to achieve therapeutic ACT is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).	I	C
Enoxaparin	•Continue enoxaparin through PCI: •No additional drug if last dose was within previous 8 h •0.3-mg/kg IV bolus if last dose was 8 to 12 h earlier	I	B
Fondaparinux	Not recommended as sole anticoagulant for primary PCI	III	Harm B

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ACS Hospital Quality Measures

Set Measure ID	Measure Short Name
AMI-1	Aspirin at Arrival
AMI-10	Statin Prescribed at Discharge
AMI-2	Aspirin Prescribed at Discharge
AMI-3	ACEI or ARB for LVSD
AMI-5	Beta-Blocker Prescribed at Discharge
AMI-7	Median Time to Fibrinolysis
AMI-7a	Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8	Median Time to Primary PCI
AMI-8a	Primary PCI Received Within 90 Minutes of Hospital Arrival